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During the past ~5 or 20 years social psychiatry has emerged as a distinctive orientation in American psychiatric theory and practice. Central to this orientation is the idea that one's social environment is a critical factor in determining the quality of one's life, including illness and health and the movement from illness to health. One's environment, it is recognized, can be pathogenic or therapeutic, destructive or potentiating. And this is true both of "natural" environments, such as the family, the schools and the quality of society as a whole, and of "artificial" environments, such as the mental hospital Traditionally, a major interest in the effects of societal structure upon the quality and possibilities of human life has been characteristic of the political theorist, reformer and revolutionary. In our time, the most systematic and influential expression of this interest is the Marxist analysis of the impact of social-economic class upon the very quality of human consciousness. Much of the new awareness and attempts of America of the ~96o's, which are centered on the extra-economic effect of poverty, class and minority status--that is, effects on the development of one's very ego and soul--are essentially nonideological (that is, pragmatic) approaches to this same problem. One can view the recent appearance of the concept of social psychiatry in a similar context, namely, an approach to the problem of the effects of social environments upon the development and quality of human life. Social psychiatry, applied to the psychiatric hospital, has led, among other things, to the idea of the therapeutic community. In 5953 a book by Maxwell Jones, The Therapeutic Community--A New Treatment Method in Psychiatry, appeared. It described the markedly positive therapeutic results of an attempt to structure the entire hospital experience in the service of therapeutic aims. A central feature of this program was the patient-staff meeting in which everyone was free to discuss issues of concern to all members of the hospital community. This innovation was introduced some time later at Yale Psychiatric Institute along with a general reappraisal of administrative and other procedures and practices in the light of the overriding question, "Is it therapeutic?" The book is essentially an account of these innovations at Yale Psychiatric Institute and of their impact upon hospital staff. The authors, one a psychiatrist and the other a political scientist, question the traditional assumptions regarding the hospital treatment of the mentally ill, in which the patient is viewed as helpless and dependent, totally incapable of making decisions affecting his life, and the doctor is regarded as the expert to whom all power and decision are given, presumably for the patient's benefit. The authors observe that even markedly disturbed patients are far more capable of rational and constructive deliberation on issues that vitally concern them than many have credited to them. If this observation is valid--and the data from the patient-staff meetings reported in the book indicate strongly that it is valid--one can no longer justify, the authors suggest, the failure to extend democratic practice

right in attributing the seat of disease in some instances to this nerve, it would be an awkward dilemma for those who confine its functions to the office of coadjutor in the process of respiration. We have heard a case in which Sir Astley Cooper lately divided the portia dura, spoken of as one of tic douloureux; but personal acquaintance with the patient enables us to contradict the statement. The lady in question had a tumor in the site of the parotid gland, which was removed, six or seven years ago, by Dr. Thomson, of Edinburgh ; at which time some branches of the portia dura were divided, and a considerable degree of paralysis of the side of the face was the consequence. This loss of power does not seem to have been restored to the same extent as when the twigs of other nerves are divided, as the writer remembers the patient in question to have remained, during the period above mentioned, with but little improvement. ".The tumor having again attained an inconvenient size, was recently extirpated by Sir A. Cooper, and a more decided palsy of the face has resulted.
To the examples above mentioned, some authors are disposed to add all those painful affections of nerves arising from external injury, (a.s bleeding,) or internal changes, (as the formation oi tumors, either in the nerves themselves, or in their vicinity, so as to irritate them by pressure ;) but at this rate there seems no limit to the term, and, as all sensation necessarily requires the medium of nerves for its communication, it would be as well to denominate every pain at once, tic douloureux. The nerves enumerated are principally those which are situated near the surface, with comparatively little covering either of fat or common integument: this, however, does not obtain universally,?-the posterior crural forming a remarkable exception ; Nor, indeed, is it easy to conceive why any nerve capable of communicating pain may not, under particular circumstances, become affected with this disease. Accordingly, examples are to be found of painful affections of internal organs, supposed 232 Critical Analysis. to resemble the neuralgia, or tic douloureux, of external nerves J and Delpech mentions an instance of the disease affecting the uterus and rectum. Although we have no doubt of the accuracy of M. Delpech, the disease having likewise manifested itself in the external distribution of the iliac nerve, yet such explanation of pains confined to internal parts ought to be received with much caution, particularly as the adoption of the tonic plan of treatment, recommended by Mr. Hutchinson, seems likely, and with justice, to gain the preference over others.
An attack of tic douloureux is sometimes, though not generally, preceded by some symptom, such as itching about the course of the nerve, which gives warning of its approach.
Sometimes the pain comes on gradually, (as in an instance now under our observation,) adding to its tortures the horror of anticipation; at others, its attack is as sudden as it is violent.
When it is once established, the peculiar intensity of the pain, in the site of a nerve, for the most part, points out unequivocally the nature of the complaint; some idea of the pain attending which may be formed from the forcible description of one of Mr. Hutchinson's correspondents. " It is not, I should conceive, possible," says he, " for any one who has not had some personal experience of this malady to form the least idea of the different effects it produces, some of which I will endeavour to enumerate.
It sometimes commences with a slight corruscation, or ticking, somewhat similar to that of a pendulum, whence it may probably.derive its name. It is afterwards succeeded by a shock more violent than that of an electrical machine, but of much longer duration. A red-hot salamander laid upon the head may afford some resemblance of the effect it sometimes produces. At other times it may convey some idea of the operation of an incision knife or tomahawk, the lancets of a cupping instrument being nothing compared to it. Sometimes you may imagine minute-guns passing through the head for a considerable length of time. The patient may, at others, suppose his head to be laid open with a battle-axe, and the brain exposed to a dreadful north-eastern blast." When we turn from a description such as this, and search our books on pathology for the cause of so much suffering, we find them lamentably deficient: not only are we ignorant of those peculiar morbid changes which produce the disease, but even the parts changed, or supposed to be so, are disputed ; some ?referring the seat of disease to the nerve, others to the brain. So far as we have considered, and can judge on this subject, we are inclined to believe the seat of disease generally exists in the nerve itself. The obvious proof is?divide the nerve, cut off the communication with the brain, and the pain ceases. This, at first sight, appears unanswerable; but then it may be asked, Yeats, Hutchinson, and Swan, on the Nerves. 233 jf we cut the infraorbitary nerve, and the pain ceases, how can it be shown but that it does so because the communication is <-ut off between the affected part and a morbid action in the brain, which requires the extremities of that nerve tor its development in the sensation of pain; and, besides, division of the nerves, so far from relieving in some cases, aggravates the pain. With regard to the latter objection, we conceive the mischief to proceed from the division being made at a Point which does not intercept the communication between the seat of disease and the brain ; as appears to have been the case in the operation for injury of the median nerve, the history of which is detailed by Sir E. Home, in the Philosophical Transactions for 1801. With respect to the former, it would seem that, when irritation exists at a point nearer the brain than that to which the sensation of pain is referred, removal of the seat of pain altogether does not necessarily alter the sensation. A gentlemen of much celebrity in our profession cut his finger last winter; the point of it remains insensible to the touch of external bodies, and yet is liable to acutely painful sensations ; showing that pain is referred to a part, the nerve of which giving the sense of touch is either not continuous, or altered in structure, by the process of re-union. But a more familiar and striking example is, that a man, sitting by his fire-side in London, shall have pain in the great toe of J>is foot, the leg having been left at Waterloo seven years ago. As this demonstrates that the brain is capable of referring pain to a part which does not even exist, so, i( the seat of tic douloureux was in the brain, we should not expect such sudden and complete cessation of pain to follow the division. It is true such relief does not invariably follow ; but this we believe to arise from an error in the part to which the disease is referred.
A tumor in the oroin will sometimes cause pain in the foot; hut, to remove this, it would be absurd to divide the nerve between them. Another singular fact is, that the pain seems occasionally referred to a part of the nerve nearer the sensation than the seat of the disease. In the case of Richard Brag, related by Mr. Pring, in his excellent " View of the Relations of the Nervous System in Health and Disease," the second branch of the fifth pair was affected with tic douloureux; the pain was most acute in the portion of the nerve within the orbit, and extending towards the lower jaw,?that is, nearer the brain than the infraorbitary foramen,?yet its division at this point completely removed the symptoms. " This fact,' says Mr. Piing, furnishes a good proof of the locality of tne disease, and is an example of the assumption that the origin of tic douloureux ls ln the nerve, and not in the brain.'" If, however, we "rant that the disease is in the nerve, we can- Critical Analysis. not prove it, by demonstrating any change in its structure. Numerous examinations have been made. It is absurd to object that the patients seldom die, and therefore that opportunities are few ; the examinations have been made under much more favourable circumstances, for the nerve has been laid bare and divided,?nay, portions of it cut out, while the patients were alive, and labouring under paroxysms of the disease; yet no morbid changes have been found, or none so uniform as to give any hint by which we may detect the ratio symptomatum. Chaussier and Bichat mention having occasionally found the femoral nerve with some degree of varix and oedema; but whether this change was cause or effect, they pretend not to determine. Inflammation is so frequent a cause of pain, that it naturally suggested itself, and, the neurilema having been fixed upon for its seat, the explanation was deemed at once obvious and satisfactory. Unfortunately, however, more extended observation did not confirm this opinion. We say unfortunately, because inflammation is an action which we are accustomed to contemplate,?which we flatter ourselves we understand,?and the effects of which we are unquestionably, in a great measure, acquainted with, and enabled to controul. Yet it is certainly a very limited view which would lead us to regard pain in a nerve as necessarily arising from inflammation; for some of the most acute pains of which we are susceptible arise from other causes: the pain, for instance, of a bloAV, or, to take a less exceptionable example, those sticbes we frequently experience in different parts of the body, which come on and go off with a rapidity which precludes the possibility of their originating in any permanent cause.
Indeed, the suddenness of the invasion, and ceasing of an attack, of tic douloureux, are of themselves sufficient grounds for the rejecting this explanation of its pathology. Pugal talks of erethism of the nerves; Fothergill of a gouty humour; and the followers of Broussais discover the acrimony of cancer either in the nerve or its sheath. Of all these hypotheses we entertain the same opinion,?they are vox et preterea nihil; and yet there must be something aliuring in this sort of speculative inquiry, for two of the writers before us have indulged in it. Mr. Swan attempts to account for the attacks of tie douloureux being periodical, in this manner: " It may be," says he, " that a nerve cannot, at first, bear a diseased action continually without rest, any more than it can a healthy one ; and therefore the diseased action, after a certain period, ceases to make any impression, or at least a much fainter one. But, after this rest, the nerve again acquires power, and is again fitted for the same action." Now, in answer to this, we would remark that, if nerves are capable of giving a continued sensation of pain in other structures, (as Yeats, Hutchinson, and Swan, on the Nerves. 235 they unquestionably are,) it is impossible to suppose that a diseased action, in themselves, will cease to produce an impression merely from fatigue, particularly as the duration of the pain is often very short; and in other instances, as inflammation pf a nerve from external injury, the pain does not intermit, but is continued. Again, he cannot help supposing " that in tic douloureux there is a sudden irregular action of the bloodvessels of the nerve," which causes the violent pain, in the same way as dizziness is produced in the eye. Now, as we cannot see the minute vessels of the nerve during this supposed action, nothing can be more difficult than to bring any direct proof against it,?except to bring any in its favour. If, however, we have recourse to analogy, we shall find it does not support Mr.
Swan's doctrine. We" do not deny that increased local actions of blood-vessels may suddenly occur; but we believe such actions do not long remain entirely local, and therefore that we may judge of the state of vessels beyond our means of direct examination by those within our reach. Thus, we cannot see the minute vessels in a whitlow; but, when we find the artery of the finger pulsating several times in the minute more than the same vessel at the wrist, we have legitimate grounds for believing the vessels in the whitlow to be in a corresponding state of excitement. But this state does not continue without affecting the artery at the wrist, likewise, to a certain extent, or even the general system; whereas, in tic douloureux, there is often, even when the nerve is superficial, no degree of increased action apparent. Neither do we admit the validity of the argument founded on the fact that Mr. Hunter had to apply a ligature to the musculo-cutaneous nerve, to stop a hemorrhage, and that he (Mr. S.) had seen the external popliteal nerve bleed profusely. These cases prove that there are painful affections ot nerves, in which the blood-vessels become enlarged: with regard to tic douloureux, they prove nothing.
The opinions of Dr. Yeats seem directly opposed to Mr. Swan's: he informs us that, in the case which he has related at full length, the veins of the affected leg were empty, and asks, " Does this condition of the veins, in a part under such excruciating pain, give any idea of the particular state of jts nerve,sr and again, " It would seem that the arteries did not sufficiently propel their contents to the veins." Thus we have two speculations with regard to the condition of the blood-vessels in tic douloureux,?one, that their action is increased, the other, that it is diminished; and we leave our readers to choose between them. We do not presume to deny that some change of structure may take place in nerves affected with tic douloureux ; we only assert that the nature of such change has never been demonstrated, and that it is not necessary that it 236 Critical Analysis.
should exist at all, because pain occurs in other parts, under circumstances which preclude the possibility of its being attended with change of structure. There are many cases where departure from natural organization has been observed in nerves, and a familiar instance of this is presented in their simple division ; it resting upon the authority of Meyer, Pring, and others, that a change of structure occurs at the place of reunion. But, where this is observed, it is accompanied with a derangement of function which is continued. We mean, that although the part, the functions of which have become impaired, may eventually recover its energy, yet that the affection is not intermittent, as in tic douloureux.
As it appears, then, that we are yet in the dark respecting the proximate cause of the disease, we cannot, in practice, avail ourselves of any indication of cure, which the possession of this secret might be expected to afford. Accordingly, the treatment has been purely empirical ; and, on looking over the list of remedies which have found their supporters, and whose claims are, of course, backed by well-attested cures, we find the simplest manner of describing them to be a reference to the whole range of the materia medica. No medicine has been deemed too deleterious, none too insignificant,?no operation has been deemed too dreadful, none too gentle ;?all has been tried, from arsenic to rhubarb,?from scarification with red-hot knives, to the more harmless application of the metallic tractors. Among these, the most obvious analogy points to narcotics,?the means which lull pain in other instances. These have been used in every dose which prudence would allow ; and opium, hyoscyamus, conium, and, more lately, belladonna and the sulphate of quinine, have been recommended. Of these, the only one, the exhibition of which in tic douloureux has fallen under our own immediate observation, is opium; and the inference we have drawn from our limited experience is, that it does not afford relief during the acute paroxysm of an attack, unless administered in such large and repeated doses as to bring on, and keep up, a state bordering upon stupor. Of all the remedies, however, carbonate of iron at present stands most conspicuous, from its novelty, and from the testimonies, both numerous and respectable, given in its favour. The evidence is before the public, and they must judge for themselves: our province is to give some of the suggestions that strike us on the perusal of different works; further than this we have neither the presumption nor the with to influence the opinion of our readers. We think it but fair, however, to add one to the list of cures: a case having recently fallen under our immediate observation, which was distinctly marked as an affection of the nerves, both by the aeuteness of the pain and its situation, affording an example., Yeats, Hutchinson, and Swan, on the Nerves.

237
Tyhich seems not to be common, of the disease attacking both sides of the face, and the exit of four branches at once. The enefit from the use of the iron was decided; its permanence remains to be proved.* I he general failure in the operation of internal remedies to remove the disease, naturally led to the idea of destroying the seat of pain, or interrupting its communication with the brain ; **nd the part which one of our authors (Mr. Swan,) has taken in investigating the phenomena attending the division of nerves, lenders it but justice to him to take some notice of this very interesting subject. The idea of dividing the nerve supplying a part affected with pain is not of modern date, although we beieve Maiiechal to have been the first who practised this operation for the relief of tic douloureux ; since then it has been clone so frequently as to render any enumeration of examples ' together unnecessary. The relief given by this operation was s? complete, as to lead to the most sanguine hopes of its permanent effect. But it was soon found that the disease, although relieved for a time, returned again in proportion as there-union ?r the nerve enabled it to discharge its usual functions. In order to remedy this evil, it was advised to cut out a portion of nerve; by which means it was supposed its continuity must be entirely and permanently destroyed. An interesting case of this kind is given by Mr. Abernethy, in which a portion of the nerve of the finger was removed, yet the sensibility of the part became restored; and Mr. Pring has mentioned a casein which three inches of the median nerve was removed : the wound ealed by the first intention, and the patient was discharged at the end of two months. " During the last three weeks of his abode in the hospital, the condition of the arm had undergone a visible improvement: its motions were in a great measure restored, and the sensibility of it was likewise considerably augmented." It is added that, in six months after the operation, the powers of the arm were so far restored " that the nian sustained little or no inconvenience in the use of it." The restoration of sensibility after the division of a nerve has been, in general, supposed to arise from its re-union, and va- We have been induced, thus early in our career, to undertake the consideration of the subject of Yellow Fever, partly from a conviction of its great importance at this moment,* and partly, also, in consequence of a promise which our predecessor has held out in a recent Number of this Journal, and which promise we were most anxious to fulfil.
We approach the discussion with a deep sense of its difficulties, and, we hope, unbiassed by any particular theory. Recent circumstances have rendered it of such intense interest, and conflicting opinions have so obscured it, that, although we may hope to be pardoned jt we fail to produce order out of this chaos, we should certainly have deserved reprehension if we had shrunk from making: the attempt. Some questions, alike interesting to the statesman and the philosopher, are involved in the inquiry concerning yellow fever; and upon the decision of one of these questions, at least, the propriety or necessity of imposing severe and irksome restraints upon a numerous class of the community entirely depends. This circumstance, which greatly enhances the value the discussion, at the same time increases the difficulty; since the evidence that relates to this particular point is by far the most contradictory that offers itself to our notice.
-Hie points to be resolved appear to be principally the three following:?1st. Is the disease that has of late years devastated j^auiz, Malaga, &c., and more recently committed such fright? U1 ravages at Barcelona, the true yellow fever, or not ? 'idly. s it an imported malady? And 3dly, (which appears to be in ju prints inform us that this disease has again made its appearance NO-283'. 242 Critical Analysis. some measure, but not entirely, dependent upon the decision of the former question,) Is it contagious, in the common acceptation of that word ??for the disease might have been contagious independently of any importation : neither does it appear to us that this latter circumstance, if proved, would be decisive of its character. Before we introduce the works that stand at the head of this article to the notice of our readers, it may not be amiss to give a rapid sketch of the history and symptoms of the yellow fever of the West Indies and America, a subject illustrated by the labours of so many celebrated men, both English and foreign; and it is not a little mortifying to the pride of human learning to observe how few facts have been established, beyond the reach of contradiction, by the exertions of such an host of writers:* yet, when we reflect upon the prejudices of education and of country,?when we consider how many enter into the inquiry with opinions already formed, and with the mental eye closed: to every circumstance that tends to weaken their pre-conceived notions,?our wonder ceases, and we can only repose in the humble hope that we, who are so sensible of their errors, may happily avoid falling into the same mistake. There Can scarcely be found a more apposite illustration of the above* remark, than the great variety of names that have been applied to denote this disease,?some imposed Upon it in order to distinguish its supposed source or origin, as themalac/j/ of Siam, the Bulafiifever, &c. ; others from a leading symptom, as the black vomit, or vomito prieto of the Spaniards; others, again, from its supposed seat, as la fievre gastro-adynamique of Pin?l; or, lastly, to suit some nosological arrangement, as Sauvages, who designates it typhus icterodes.
,In. tracing the history of yellow fever, it is curious to observe' how very conspicuous a place the doctrine of importation will be fotind to occupy ; and that attempts have been made, as early as the year I69O, to fix the origin of the disease upon the' East Indies; but the argument in this instance is so well known to be contradicted by established facts, and the prior existence of yellow fever in the Brazils, at Martinique, St. Domingo, &c.
is so amply proved, that it will not be necessary to recur to any authority to establish this point: indeed, two of the authors* i lie following is a brief sketch of the usual mode in which yellow fever makes its attack. Its first accession is denoted by cold chills or rigors, soon succeeded by intense heat and dryness ?t the surface of the body;* the face is red and flushed ; the e}es have a peculiar and fiery expression, which has been compared to those of a man in a state of intoxication; violent pains ?ire f0lt jn tjje forehea(] ancj orbits, sometimes more particularly ln the back and lumbar region ; the countenance sometimes exhibits a remarkable expression of alarm ; the .tongue, at first moist, soon becomes loaded ; the patient complains of nausea and tenderness in the epigastrium ; troublesome eructations aud vomitings of bilious matter quickly succeed, which, as the disease advances, become of a darker colour; the thirst is extremely great ; restlessness and watchfulness distress the sufferer to a great degree; and this stage of the disease often lasts as long as two, ov even three, days. The condition of the bowels ners very much: in some instances, constipation exists to a very remarkable extent. One of the distinctive marks of the complaint, mentioned by Mr. Bally, is the length of time that t ie energy of the muscular power is sustained, so that a person shall be able to walk the street, or shave himself, within an hour ?r his death. At the termination of this stage, the more prominent symptoms, in general, remit: the patient and his friends a.le induced to believe that he has overcome the malady ; but the listless and often torpid state of the patient, and a faint yellowish appearance about the chin, or on the sclerotic coat of tnc eye, too surely point out the danger that is lurking beneath tins apparent calm. Dr. Bancroft observes, as an alarming symptom in this stage of the complaint, that pressure made upon the region of the stomach will occasionally produce efforts to vomit; although the pulse shall have diminished in fre- clear. This, which may be called the second period of the disease, seldom lasts above two days, and is succeeded by renewed vomitings: the matter thrown up is streaked, or altogether black; passive hemorrhages from the mouth, anus, &.c. supervene ; the teeth and gums are covered with a black crust; the dejections become bloody, of a most offensive kind, and often involuntary; the urine is dark coloured, foetid, and in .very small quantity ; petechias occasionally appear over the whole body, some hours previous to death. Swellings of the parotids, and of the axillary glands, are mentioned by some authors, but they do not seem to be essential to the disease: they were, however, met with frequently at Martinique, in 1802 and 1803.* The state of the intellects is by no means uniform: sometimes coma prevails; in other epidemic seasons, furious delirium has Jbeen more prevalent. The whole duration of the malady is from five to seven days, although many instances occur where death ensues within thirty-six or even twenty-four hours. The state of the pulse is represented as very variable. Dr. Gordon says that, at the commencement of the re-action, it is full and strong, but seldom exceeding ninety strokes in the minute.
Dr. Bancroft represents it as quick, though sometimes oppressed and irregular. At the end of the first twenty-four hours it increases in frequency.
It appears, by the concurrent testimony of some of the best ?writers, that yellow fever attacks the system most commonly between midnight and noon.
So much do these epidemics vary in their leading symptoms, that, in 1814, it is said that the black .vomit was a rare occurrence.
At Philadelphia, in 1798, the delirium was generally of a violent character. In some instances, a miliary eruption has made its appearance in the latter stage of the malady ; and even the yellow suffusion is not always met with.t Examination of the dead body presents more points of difference than would at first sight be expected ; and authors by no means agree in their accounts of the diseased appearances. These disagreements may, perhaps, be ascribcd to the greater or less degree of severity of individual cases, or to variations in the epidemic constitution (to use an antiquated phrase,) of some particular seasons.
Thus, whilst Bancroft declares that the brain has appeared to him more voluminous than natural, Mr. Bally has ?found it compressed by a red and bloody-looking serum; and Savaresi says that it is, in general, reduced to five-sixths of its usual volume. In some seasons, the lungs have been found * M. de Jouncs, t Dicliunnuiie des Scienccs Mcilicalcs, Remarks on the Yellow Fever. 245 affected, and the pleura inflamed ; but the abdomen is the principal seat of the morbid changes,.though even here we find a great contrariety of sentiment. Dr. Gordon has found the biliary organs frequently in a state of lesion; others have observed that the liver and gall-bladder remain in a healthy state, even where the stomach is loaded with the matter of black vomit. Gerardin* has often seen the hepatic system unaltered ; whereas Rochoux protests that there is no example of the gall-bladder remaining in a healthy state. It is admitted that the spleen and kidneys are generally sound ; yet ^avaresi observed, at Martinique, in 1803 and 1804, that they were constantly affected. The mucous surface of the stomach and small intestines bears, however, the most unequivocal and universal marks of lesion, according to the unanimous testimony of all the best writers. Red and gangrenous spots are found scattered over their whole surface; and, finally, ?)r. Audouard informs us that, in numerous instances, the spinal canal contains a quantity of serous fluid. We will not fatigue or insult our readers by quoting authorities to prove that yellow fever is indigenous in the New World ; that it is of local origin, and can be fairly traced to the extrication of marsh effluvia, reigning sporadically, in a greater or less degree, among Europeans and new settlers; whilst the natives and the black population, excepting in particular seasons, escape with impunity, or, at most, only suffer partially and occasionally from slight remittent or intermittent fever.
We are still, however, in darkness with respect to the causes which sometimes give vigour and activity to this poison at one Period more than another, and which, after a few years' quiescence, render these climates so formidable to the inhabitants of our quarter of the globe ; particularly hot seasons,?the fall of an unusual quantity0of rain,?the direction of the winds,?the absence or presence of hurricanes, and other atmospheric phenomena, would probably, if duly registered and known, solve the difficulty. But this is a subject standing in need of much illustration, and the study of which we strongly recommend to those whose destiny carries them to these climates.
A caretuI inquiry into the topography of the different islands and places where the disease is to be met with, is also a gieat desideratum; although, since the year 1793, many important facts relative to this point have been noticed, both by 'English and foreign writers, f It is a pursuit of the highest importance, because it leads at once to the only remedies that can prevent a recurrence of the dreadful scenes that have been too common both in America and its islands; and which remedies, it has * Ulemoiressurla FievreJiiune. + Ferguson, liuncioit, Watts, llcverc, Gerardin, ccc* 246 Critical Analysis* been, we think, satisfactorily shown, consist in ventilation, drainage, and cultivation. That, from the year 1793, in particular, such frightful mortalities should have occurred in St. Domingo and other of the Antilles, is not a subject of astonishment, when we consider the thousands of victims, in the fittest state to receive the disease, which the course of a sanguinary war poured out to these colonies.
We may now fairly proceed to examine the authorities on the much-disputed subject of contagion, which we shall do as briefly as possible, and then turn our attention to the disease which has appeared so frequently, of late years, on the coast of Spain and Italy; which will conduct us to the question of importation, and to its application to the recent case of Barcelona, in particular.
Several opinions appear to have been prevalent relative to the contagious character of yellow fever, by which term we understand a direct communication with the sick, or with the clothes, bedding, &c. of persons labouring under the disease.
One of these opinions is, that it is contagious ; another, that it is not; and a third and respectable portion, both as to reputation and numbers, hold a middle course, and believe that it is sometimes contagious and sometimes not so; whilst others, refining still farther, believe that, though not originally capable of communication, it may, under certain circumstances, become so, or that the contagious property has but an extremely limited operation in point of time as well as space. Among the contagionists are to be found the names of Lind, Lining, M'Kettrick, With respect to Mr. Rochoux, we know not what to say; he seems to have changed his opinion so often, that it may fairly be doubted whether be has made up his mind as to which side of the question he finally intends to espouse. It is more than suspected that Dr. Rush, although he had formally abjured his belief in contagion, retained a strong predilection for that doctrine to his last hour.
In the very outset of the argument, it will be perceived that the non-contagionists have a manifest advantage over their antagonists, because one well-authenticated fact of non-contagion is, from its nature, of more value, than scores of cases of contagion as usually adduced ; for, as these latter necessarily take place upon the spot which is the alleged source and origin of Remarks on the Yellow Fever. 247 noxious effluvia,?the very cradle of the disease, twenty 6*1 may successively fall ill from breathing the same atmori WIt^out 'ts being at all necessary to suppose they dej V Jt from each other : nor does the exemption of secluded ouses and families, even if the facts are admitted in their u est extent, entirely clear up the difficulty; since it is well fiown that, in other cases of marsh fever, and upon sundry er occasions, the slightest difference of situation,?the interposition of a wall or dyke,?;has been quite sufficient to preserve the atmosphere from contamination. In Walcheren, this *yas exemplified in numerous instances, especially at Fort Batz, V'ere the troops suffered little or no sickness; whereas, those s ationed without the fort, though only at a very short distance, ^ere affected by the fever to a most alarming extent and de-foCer' ^ut what shall we say to the instance of New-York, in .505, where a population of more than 10,000 persons, dreadlng the effects of contagion, fled from the town, and encamping at ^r5enwich, an elevated field at one extremity of the town, established their stores, banking houses, &c. on that spot, and 2 *9 .for our purpose to notice two or three of the most striking il" lustrations he has given us in support of the non-contagious J^ture of yellow fever, without entering into the merits of his "pinions upon other points of the argument. The first of these facts is the exemption which all the inhabitants of Monk s-Hill -Barracks, Antigua, enjoyed during the epidemic of 1816, whose duty did not oblige them to sleep out of that garrison ; whereas the soldiers who mounted guard at the dock-yard, and in other low situations, were often seized, while on their posts, with the most aggravated form of the disease; many dying within thirty hours from the first attack. Another important observation goes to prove that a slight elevation in the immediate vicinity ?f a marsh is more fatal sometimes than the ground upon a level with it, the higher ground appearing to attract the effluvia. This is in conformity with our own experience in the case of intermittent fever in many situations in this country. _ . .
Upon the whole, then, the conviction upon our minds arising from all we have read and thought upon this subject, is, that yellow fever is not a contagious disease; that it is of local origin; that it exerts its energy principally during night, at which time a very transient and temporary exposure to its causes is sufficient to light up the flame in a habit predisposed to receive it; and that although, from causes yet unknown, it acquires such fatal activity at some particular seasons, it is always to be met with as a sporadic atlection in those climates, and, if we may believe some authors, even at our own doors.* -Notwithstanding all these articles of faith, we are, howevci, willing to admit that the conviction entertained by some very judicious practitioners, that, although not originally or necessarily contagious, yellow fever may, and does, occasionally become so, is not to be altogether despised; since there docs not appear any thing unreasonable in the supposition, that crowded habitations, poverty of living, and personal uncleanliness, ( Critical Analysts. the poisonous effluvia as to superadd a contagious property to a disease originally free from it. We do not know this to be 252 Critical Analysis, that the yellow fever broke out spontaneously on-board a vessel callcd the Euryalus, cruising in the tropical seas, without having touched at any port in those seas; and this he declares to be the fifth instance of the kind, within his own knowledge, in a period of four years. M. Moreau de St. Mery adduces the following fact as an unanswerable argument in favour of contagion : we do not see it in that light; however, we are bound in candour to relate it. The Palenicrus, a French brig, having the yellow fever onboard, and cruising in the West Indies, encountered the English brig Carnation, coming direct from Europe, the crew quite healthy. A combat ensued, and the English brig was captured (a rare occurrence,) by boarding: the English sailors were consequently removed as prisoners into the French ship, and took the disease. Now, we think this and other examples quoted above will enable us to clear up this difficulty, without the necessity of recurring to contagion ; for, if the French vessel was the focus of the yellow fever in this last instance, she would stand, in relation to the English sailors, exactly as a village or town surrounded by a contaminated atmosphere would stand with respect to its inhabitants, or to strangers arriving there go the whole length of proving that the malady produced was actually the yellow fever; but they establish this fact, that the putrefaction of animal and vegetable matter, aided by -warmth and moisture, is capable of producing a disease resembling yellow fever in some of its most prominent features, as well as its ratio of mortality. From a due consideration of the foregoing facts, and many others equally strong, resting on authorities the most respectable and undoubted, we do not perceive any thing paradoxical the assertion, that, whilst we believe yellow fever to be in its mature non-contagious, we are clearly of opinion that it may be, and often has been, imported. That it has ever spread by importation, or that the mortalities that have occurred so frequently in the New World, as well as in Europe, are to be ascribed to this source, we most positively deny; but when, from a concurrence of local causes, an epidemic has broken out, and it becomes an object to trace it to some palpable and known origin, can we be surprised that it should be discovered to have existed on-board some ship from the West Indies, or that it should have developed itself on-board some vessel during her passage? In fact, numerous examples of the sort are upon record; but does this circumstance establish a necessary connexion between the disease on-board and the epidemic on-shore? We think decidedly not; for repeated experience has shown that men brought from 011 ship-board, and dying of yellow fever at different houses, have not spread the disease to any single indiyidual; and, again, epidemics have sometimes raged, of the importation of which not only no evidence is offered, but not even any suspicion existed. The shores of the Mediterranean have enjoyed an exemption from this calamity for many successive years. Is it reasonable to suppose that, in all that time, the quarantine laws have never been violated or evaded, when such instances are discovered to be of every-day occuucnce, when they are wanted to be brought forward as evidence of the foreign origin of the complaint ? But, in truth, such inquiries have never been thought of until the breaking-out of the fever has given rise to them ; and, when instituted, if a solitary case ?f yellow fever has been traced to have occurred within a short period of the invasion of ;the malady, the problem has been considered as solved, and all collateral and minor evidence tortured to meet this explanation. But, if we believe that, in any. one well-attested instance, yellow fever has been traced from a West Indian or American vessel without communicating contagion, the argument in favour of that doctrine is at an end, and importation may still be credited without considering contagion as a necessary consequence. ' Tiie coursc of our narrative has now brought ub to the ccnsi-*151 Critical Analysis. deration of those frightful scenes which have occasionally been exhibited on the shores of Italy and Spain, but which have, since the year 1800, been not only of more frequent occurrence, but more fatal in their results. That Cadiz, Carthagena, and Malaga, have been visited three or four times in the course of the eighteenth century by destructive epidemics, and that these epidemics were really the'yellow fever, there can be no manner of doubt. The writings of contemporary authors are conclusive upon this point, and Lind was himself a witness to one of these visitations. The more recent occurrences at Cadiz and Gibraltar have given birth to such numerous testimonies of the most respectable kind, that there can be no hesitation in asserting that the first of our questions is satisfactorily answered in the affirmative ; and nothing now remains for us but to examine the documents that relate to the fever at Barcelona in 1821, and the only point of accordance that can be discovered between the various individuals who have so zealously devoted themselves to the contemplation of this malady, is the undoubted fact of its having been the yellow fever.
We shall now, without farther comment, proceed?1st, to lay before our readers, as succinctly as we are able, the substance of the Report made by the French commissioners to their government relative, to this epidemic, as bearing the stamp of authority: and afterwards present them with a Manifesto, published by the spontaneous union of several physicians, both English, French, and Spanish, in Barcelona, and which is, in fact, a direct contradiction to all the assertions contained in that report, without having been originally intended as such ; since, at the time of its publication, the report of the French commissioners was not known at Barcelona. In the course of this analysis, all the facts connected with this melancholy visitation of Providence will become developed; and the conclusions which Ave think must inevitably result, will tend, in a very satisfactory manner, to confirm the opinions attempted to be maintained in the former part of this paper.
With regard to the report of the French commission, it is but cold language to say that it is one of the most extraordinary documents ever presented to public notice: it would, perhaps, not be too harsh to affirm that it is also the feeblest in reasoning, -r? the weakest in fact, and the.strongest in assertion, that ever issued Irom the press. It bears the most decided marks of preconceived opinions, but is, fortunately, so hastily and crudely put together as to carry the conviction of its weakness in every page: in short, it displays a determination to discover, what we .are persuaded it was intended to find, an excuse for a sanitary cordon.
The gentlemen composing this commission were originally five in number,?namely, Messrs. Bally, Francois, 260 Critical Analysis. at the same time. Messrs. Bally, &c. (he continues,) went about seeking only those facts which appeared to favour their own cause; and, in reply to their remark, that one positive fact is equal to thousands of negatives, he says that their positive facts lose all their force when submitted to the test of rigid criticism ; a point which, unless we deceive ourselves, we have sufficiently shown above.
In the Lazaretto, in the Hospital of the Seminary, in the General Hospital, neither the medical men nor those who attended the sick suffered the slightest attack. The sisters of the General Hospital escaped with perfect impunity ; whereas the purveyor, the apothecary in chief, and others who never entered the wards, and who studiously avoided all contact with the sick, experienced an attack. It is impossible to find, he adds, one single well-attested instance of a sick person quitting the town, and spreading the disease to any of the neighbouring communes; and he urges the strong fact of the inhabitants of Sans, Garcia, and many other places, having escaped the disease, notwithstanding they were included within the cordon which enclosed Barcelona. Hence he thinks it extremely unlikely that contagion could be brought from the Havannah, when even the small distance of Garcia from the city was found sufficient to impede its communication. Upon the authority of these names, it is asserted that sporadic cases of yellow fever were met with both at Barcelona and Barcelonetta, as early as February and March of the year 1821; and Dr. Lopez himself was called in consultation to a man who dwelt behind the Exchange, and who died of yellow fever, with petechias anil black vomit, in the early part of February; and it will be recollected that the accused vessels did not reach the port until the latter end of June. After the disease broke out, numbers of sick retired to Sitjes, Malgrat, &c. but no sickness ensued at those places.
With regard to Tortosa, where the fever was supposed to have been introduced by a dealer in hams, the Junta of Health affirm that, many days prior, a sick man was brought from onboard a bark that had never been at Barcelona. It is to be remarked also, that towards the end of summer, that town is always visited by fevers of a very violent character.
With respect to the state of the port, it is asserted, that such was the condition of the sewers, the canals in the streets, &e. that, towards the end of June, it was impossible to pass along Remarks on ihc Yellow Fever. 281 the sea-wall without being inconvenienced by the stench produced by the decay of animal and vegetable matter in its vici-R'ty. The examination performed by the commission charged with cleansing the port, proves that the Arequia was obstructed at its mouth by a sandbank, which had caused the accumulation ?f a mass of stinking water, loaded with the impurities furnished hy all the manufactories, slaughter-houses, &c. situated upon the banks of this rivulet, from whence a most insupportable stench arose. The modern works of the port appear to have increased the evil, and have produced a source of infection which did not formerly exist.
The mortality was most especially great in those streets in the line of the port; whereas, in those exposed to the north, and more distant from the infected spot, but few sick were found.
The time of the year in which the fever broke out is precisely the period in which epidemics make their invasion in hot countries : this fact has been verified more than once in Spain. The fever has not been able to establish itself beyond the walls of Barcelona. No person has been proved to have caught the disease out of the sphere of the operation of local causes.
At the Marine Lazaretto, between the 7th of August and the 13th of September, 79 cases were received, 55 of whom died: not one individual, out of 32 employed in that establishment, took the disease. At the Seminary, 1767 sick were admitted, 129S died; but only three cases of the fever occurred among go people employed in that establishment.* M. Ribera, in dissecting a body, wounded his finger deeply with the scalpel: nothing beyond a slight swelling of the axillary glands took place.
Many, who had suffered from the disease in America, contracted it again, and some of these died. Many families, who secluded themselves in the most rigorous manner, found their precautions in vain.
At the time the barrier was placed at Barcelonetta, on the 3d of September, there were only nine sick in the place: on the iOth instant, they amounted to 162; and, finally, Those who had quitted the place with all their effects did not spread the disease at their new residences ; although some few died of yellow fever, which they carried with them.
Such, among many others, are the strong, and we think unanswerable, facts which the perusal of this able paper has enabled us to Jay before our readers, as confirming the view we have taken of this complicated and highly interesting subject. We, perhaps, have been tedious, and have accumulated evidence which many may consider as redundant; but we were anxious